Indoor radon exposure and active and passive smoking in relation to the occurrence of lung cancer

Exposure to indoor radon and radon daughters is currently attracting great interest as a possible cause of lung cancer. This concern is supported by several studies, most of them relatively small in numbers or weak in the assessment of exposure. This study encompasses 177 persons with lung cancer and 677 noncancer referents, all deceased and with 30 years or more of residency in the same house in an area with radon-leaking alum shale deposits in the central part of southern Sweden. Exposure categories based on building material, type of house, and ground conditions were created, but measurements of the indoor radon daughter concentration were also made for 142 cases and 264 referents. Active and passive smoking was ascertained through questionnaires sent to the next-of-kin. Overall, the lung cancer risk was approximately twofold with regard to the categories of assumed radon daughter exposure for the rural sector of the population but not for the same categories of the urban sector, possibly because of less precise exposure assessment and influence from other factors. Occasional and passive smokers, as well as passive smokers alone, had a particularly increased risk of lung cancer in association with the increased exposure categories.     

Lung cancer and residency--a case-referent study on the possible impact of of exposure to radon and its daughters in dwellings.

In view of the well-known urban-rural difference in lung cancer rates, remaining also after standardization for smoking, it is suggested that low levels of radon and its daughters in dwellings might be of etiologic importance to this disease. To test this hypothesis, a case-referent (case-control) study was undertaken in a rural area; it considered residency in wooden houses (assumed to be associated with low-level exposure to radon and its daughters), "mixed type" houses (medium exposure) and stone houses (high-level exposure) among cases of lung cancer and referents (controls). The results indicate an increased risk of lung cancer among residents in "mixed type" and stone houses. Additional studies are highly desirable to confirm or refute these findings, which, if valid, mean increasing lung cancer hazards caused by a decrease in ventilation in future energy saving unless special measures are undertaken to reduce radon daughters in dwellings.     

Radon in homes--a possible cause of lung cancer

An earlier case-referent study [Scand j work environ & health 5 (1979) 10-15] has indicated a possible relationship between lung cancer and exposure to radon and radon daughters in dwellings. Indoor radon concentrations seem to depend on both building material and leakage of radon from the ground. This new study, in a rural area, is a further attempt to elucidate the etiology of lung cancer, taking into consideration type of house and ground conditions, as well as smoking habits. Although the choice of a rural study population helped to eliminate various confounding exposures in the urban environment, it limited the size of the study because of the rareness of lung cancer in rural populations. Long-term residents, 30 years or more in the same houses, were studied, and again an association was found between lung cancer and estimated exposure to radon and radon daughters in homes. The data also seem to indicate the possibility of a multiplicative effect between smoking and exposure to radon and radon daughters in homes, but there was also some confounding between these factors in the data.     

Indoor radon and lung cancer in France

BACKGROUND: Several case-control studies have indicated an increased risk of lung cancer linked to indoor radon exposure; others have not supported this hypothesis, partly because of a lack of statistical power. As part of a large European project, a hospital-based case-control study was carried out in 4 areas in France with relatively high radon levels. METHODS: Radon concentrations were measured in dwellings that had been occupied by the study subjects during the 5- to 30-year period before the interview. Measurements of radon concentrations were performed during a 6-month period using 2 Kodalpha LR 115 detectors (Dosirad, France), 1 in the living room and 1 in the bedroom. We examined lung cancer risk in relation to indoor radon exposure after adjustment for age, sex, region, cigarette smoking, and occupational exposure. RESULTS: We included in the analysis 486 cases and 984 controls with radon measures in at least 1 dwelling. When lung cancer risk was examined in relation to the time-weighted average radon concentration during the 5- to 30-year period, the estimated relative risks (with 95% confidence intervals) were: 0.85 (0.59-1.22), 1.19 (0.81-1.77), 1.04 (0.64-1.67), and 1.11 (0.59-2.09) for categories 50-100, 100-200, 200-400, and 400+ becquerels per cubic meter (Bq/m), respectively (reference <50 Bq/m). The estimated relative risk per 100 Bq/m was 1.04 (0.99-1.11) for all subjects and 1.07 (1.00-1.14) for subjects with complete measurements. CONCLUSIONS: Our results support the presence of a small excess lung cancer risk associated with indoor radon exposure after precise adjustment on smoking. They are in agreement with results from some other indoor radon case-control studies and with extrapolations from studies of underground miners.     

A case-referent study of lung cancer and incense smoke, smoking, and residential radon in Chinese men

Background: Burning incense generates large amounts of air pollutants, many of which are confirmed or suspected human lung carcinogens.Objectives: We conducted a population-based case-referent study to examine the effect of incense smoke exposure on lung cancer risk among Chinese males and explored the joint effect of cigarette smoking and exposure to residential radon.Methods: We recruited 1,208 male lung cancer incident cases and 1,069 community referents from 2004 to 2006 and estimated their lifetime exposures to incense smoke and other residential indoor air pollutants based on self-reported information collected during interviews. We performed unconditional multivariable logistic regression analysis to estimate the odds ratio (OR) for lung cancer associated with exposure to incense smoke after adjusting for possible confounders. We conducted stratified analyses by smoking status and exposures to incense burning and residential radon and explored the potential additive-scale interactions.Results: We observed an association between incense exposure and lung cancer that was limited primarily to smokers. Cigarette smoking and high cumulative incense exposure at home appeared to have a synergistic effect on lung cancer (compared with never-smokers who never used incense, the OR for lung cancer for smokers who used incense ≥ 60 day-years = 5.00; 95% confidence interval: 3.34, 7.51). Power was limited, but we also found preliminary evidence suggesting that radon exposure may increase risk among smokers using incense.Conclusion: Our study suggests that exposure to incense smoke in the home may increase the risk of lung cancer among smokers and that exposure to radon may further increase risk.     

Case-control study on lung cancer and residential radon in western Germany

In a 1990-1996 case-control study in western Germany, the authors investigated lung cancer risk due to exposure to residential radon. Confirmed lung cancer cases from hospitals and a random sample of community controls were interviewed by trained interviewers regarding different risk factors. For 1 year, alpha track detectors were placed in dwellings to measure radon gas concentrations. The evaluation included 1,449 cases and 2,297 controls recruited from the entire study area and a subsample of 365 cases and 595 controls from radon-prone areas of the basic study region. Rate ratios were estimated by using conditional logistic regression adjusted for smoking and for asbestos exposure. In the entire study area, no rate ratios different from 1.0 were found; in the radon-prone areas, the adjusted rate ratios for exposure in the present dwelling were 1.59 (95% confidence interval (CI): 1.08, 2.27), 1.93 (95% CI: 1.19, 3.13), and 1.93 (95% CI: 0.99, 3.77) for 50-80, 80-140, and >140 Bq/m3, respectively, compared with 0-50 Bq/m3. The excess rate ratio for an increase of 100 Bq/m3 was 0.13 (-0.12 to 0.46). An analysis based on cumulative exposure produced similar results. The results provide additional evidence that residential radon is a risk factor for lung cancer, although a risk was detected in radon-prone areas only, not in the entire study area.     

The residential radon-lung cancer association in U.S. counties: a commentary

There is little doubt that underground miners exposed to radon and its progeny have increased rates of lung cancer. Residential radon exposures should carry a possibly smaller risk of increased cancer. When it became possible to collect radon data in a large number of U.S. homes and the data were aggregated by counties, the apparent association with lung cancer was a negative one, even when many other variables were taken into account. Residential radon levels are higher in suburban residences leading to a negative association with population density. Population density is strongly positively associated with lung cancer. It follows that aggregate residential radon and lung cancer rates should be negatively associated for reasons having nothing to do with the possibility of radon being carcinogenic to the lung. A second problem presented by the data is the one of sampling bias since the county lung cancer data are from the whole county population, but only a few residences are tested. Examples of other inherent associations in environmental epidemiology are cited. One strategy is to study areas of the same population density but with radon exposure gradients. This is approximated by choice of rural high radon states. Counties in such states have weak and inconsistent associations between radon and lung cancer, some of which are positive. I conclude that counties are generally inappropriate units for study of radon and lung cancer associations.     

Residential radon and risk of lung cancer: a combined analysis of 7 North American case-control studies

BACKGROUND: Underground miners exposed to high levels of radon have an excess risk of lung cancer. Residential exposure to radon is at much lower levels, and the risk of lung cancer with residential exposure is less clear. We conducted a systematic analysis of pooled data from all North American residential radon studies. METHODS: The pooling project included original data from 7 North American case-control studies, all of which used long-term alpha-track detectors to assess residential radon concentrations. A total of 3662 cases and 4966 controls were retained for the analysis. We used conditional likelihood regression to estimate the excess risk of lung cancer. RESULTS: Odds ratios (ORs) for lung cancer increased with residential radon concentration. The estimated OR after exposure to radon at a concentration of 100 Bq/m3 in the exposure time window 5 to 30 years before the index date was 1.11 (95% confidence interval = 1.00-1.28). This estimate is compatible with the estimate of 1.12 (1.02-1.25) predicted by downward extrapolation of the miner data. There was no evidence of heterogeneity of radon effects across studies. There was no apparent heterogeneity in the association by sex, educational level, type of respondent (proxy or self), or cigarette smoking, although there was some evidence of a decreasing radon-associated lung cancer risk with age. Analyses restricted to subsets of the data with presumed more accurate radon dosimetry resulted in increased estimates of risk. CONCLUSIONS: These results provide direct evidence of an association between residential radon and lung cancer risk, a finding predicted using miner data and consistent with results from animal and in vitro studies.     

Clinical measures, smoking, radon exposure, and risk of lung cancer in uranium miners.

OBJECTIVES: Exposure to the radioactive daughters of radon is associated with increased risk of lung cancer in mining populations. An investigation of incidence of lung cancer following a clinical survey of Ontario uranium miners was undertaken to explore whether risk associated with radon is modified by factors including smoking, radiographic silicosis, clinical symptoms, the results of lung function testing, and the temporal pattern of radon exposure. METHODS: Miners were examined in 1974 by a respiratory questionnaire, tests of lung function, and chest radiography. A random selection of 733 (75%) of the original 973 participants was followed up by linkage to the Ontario Mortality and Cancer Registries. RESULTS: Incidence of lung cancer was increased threefold. Risk of lung cancer among miners who had stopped smoking was half that of men who continued to smoke. There was no interaction between smoking and radon exposure. Men with lung function test results consistent with airways obstruction had an increased risk of lung cancer, even after adjustment for cigarette smoking. There was no association between radiographic silicosis and risk of lung cancer. Lung cancer was associated with exposures to radon daughters accumulated in a time window four to 14 years before diagnosis, but there was little association with exposures incurred earlier than 14 years before diagnosis. Among the men diagnosed with lung cancer, the mean and median dose rates were 2.6 working level months (WLM) a year and 1.8 WLM/year in the four to 14 year exposure window. CONCLUSIONS: Risk of lung cancer associated with radon is modified by dose and time from exposure. Risk can be substantially decreased by stopping smoking.     

Lung cancer and indoor air pollution in rural china

PURPOSE: Indoor air pollution has been linked with lung cancer in China. In contrast to previous studies conducted in urban areas with high levels of industrial pollution, we undertook a lung cancer case-control study in a rural area of China, where residents live in underground dwellings. We evaluated the effects of radon, wood and coal combustion, cooking oil fumes, and environmental tobacco smoke on lung cancer risk.METHODS: We enrolled 886 lung cancer cases (656 males, 230 females) diagnosed between 1994-98, aged 30-75 years and 1765 frequency matched population-based controls from two prefectures in Gansu Province in Northwestern China. We conducted interviews with subjects or next of kin on smoking, housing characteristics, fuel use and cooking practices. Year-long radon detectors were placed in current and former homes of subjects.RESULTS: Subjects primarily used coal (22%), wood (56%) or a combination of both (22%) for heating. Odds Ratios (OR) for lung cancer rose with increasing percent of time that coal was used to heat homes over the past 30 years (ORs = 1.00, 1.17, 1.35, 1.23 compared to wood only, adjusted to smoking, P for trend = 0.025). Among non-smoking females and males, the OR for ever exposed to environmental tobacco smoke was 1.19, 95% CI = 0.7-2.0 with a significant trend for increasing years of exposure. Fumes from cooking with rapeseed oil increased the risk of lung cancer (OR = 1.56, 95% CI = 1.0-2.5) among non-smoking women. Among these women, occasional and frequent eye and throat irritation during cooking appeared to be associated with increased risk of lung cancer (ORs = 1.00, 1.42, 2.28, p trend < 0.01), whereas, increasing level of smokiness during cooking did not appear to affect risk.CONCLUSIONS: There is a suggestion that coal used for heating, environmental tobacco smoke, and cooking oil fumes contribute to the risk of lung cancer in this rural area of China.     

Models for retrospective quantification of indoor radon exposure in case-control studies

In epidemiologic studies on lung cancer risk due to indoor radon the quantification of individual radon exposure over a long time period is one of the main issues. Therefore, radon measurements in one or more dwellings, which in total have been inhabited by the participants for a sufficient time-period, are necessary as well as consideration of changes of building characteristics and ventilation habits, which influence radon concentration. Given data on 1-y alpha-track measurements and personal information from 6,000 participants of case-control studies in West and East Germany, an improved method is developed to assess individual radon exposure histories. Times spent in different rooms of the dwelling, which are known from a personal questionnaire, are taken into account. The time spent outside the house (average fraction 45%) varies substantially among the participants. Therefore, assuming a substantially lower radon exposure outside the dwelling, the residence time constitutes an important aspect of total radon exposure. By means of an analysis of variance, important determinants of indoor radon are identified, namely constant conditions such as type of house (one family house or multiple dwelling), type of construction (half-timbered, massive construction, lightweight construction), year of construction, floor and type of basement, and changeable conditions such as heating system, window insulation, and airing habits. A correction of measurements in former dwellings by factors derived from the analysis is applied if current living conditions differ from those of the participants at the time when they were living in the particular dwellings. In rare cases the adjustment for changes leads to a correction of the measurements with a factor of about 1.4, but a reduction of 5% on average only. Exposure assessment can be improved by considering time at home and changes of building and ventilation conditions that affect radon concentration. The major concern that changes in ventilation habits and building conditions lead to substantial errors in exposure (and therefore risk) assessment cannot be confirmed in the data analyzed.     

Residential radon and risk of lung cancer in an Italian alpine area

To evaluate whether residential radon exposure explains the excess mortality for lung cancer in an Italian alpine valley with high natural radioactivity, the authors conducted a population-based case-control study on 138 deceased cases and 291 sex- and year-of-birth-matched controls. Year-long alpha-track measurements of radon were performed in the most recent residence, and information about occupational history and lifetime smoking habits was obtained. The authors adjusted for smoking, and radon was associated with lung cancer risk among men: compared with a radon level of < 40 becquerels (Bq) per cubic meter (m3), the odds ratios for 40-76 Bq/m3, 77-139 Bq/m3, 140-199 Bq/m3, and 200+ Bq/m3 were 2.1, 2.0, 2.7, and 1.4, respectively. The association between radon and lung cancer, as determined with a multiplicative model, was found only among male smokers.     

Adult myeloid leukaemia and radon exposure: a Bayesian model for a case-control study with error in covariates

The possible association between radon exposure in dwellings and adult myeloid leukaemia had been explored in an Italian province by a case-control study. A total of 44 cases and 211 controls were selected from death certificates file. No association had been found in the original study (OR = 0.58 for > 185 vs 80 < or = Bq/cm). Here we reanalyse the data taking into account the measurement error of radon concentration and the presence of missing data. A Bayesian hierarchical model with error in covariates is proposed which allows appropriate imputation of missing values.The general conclusion of no evidence of association with radon does not change, but a negative association is not observed anymore (OR = 0.99 for > 185 vs 80 < or = Bq/cm). After adjusting for residential house radon and gamma radiation, and for the multilevel data structure, geological features of the soil is associated with adult myeloid leukaemia risk (OR = 2.14, 95 per cent Cr.I. 1.0-5.5).     

Human radiation action of radon and its daughter disintegration products

Radon-222 and its daughter disintegration products are present within all the buildings without except, which is an inevitable source of radiation both in the dwellings and in working places. There may be higher concentrations of radon in some regions. Seasonal radon level changes depending on ambient air temperature and atmospheric pressure have been found in the atmospheric ground layers. The results of the performed sanitary-and-epidemiological studies may state that there is a cause-and-effect relationship between the level of radon in the air of accommodations and the higher incidence of lung cancer. Radon-resistant structures of dwellings, removal of the soil sources of radon, as well as air filtration and efficient ventilation of premises are basic methods for decreasing the concentration of radon.     

Residential radon and risk of lung cancer in Eastern Germany

BACKGROUND: There is suggestive evidence that residential radon increases lung cancer risk. To elucidate this association further, we conducted a case-control study in Thuringia and Saxony in Eastern Germany during 1990-1997. METHODS: Histologically confirmed lung cancer patients from hospitals and a random sample of population controls matched on age, sex and geographical area were personally interviewed with respect to residential history, smoking, and other risk factors. One-year radon measurements were performed in houses occupied during the 5-35 years prior to the interview. The final analysis included a total of 1,192 cases and 1,640 controls. Odds ratios (OR) and 95% confidence intervals (CI) were estimated by logistic regression. RESULTS: Measurements covered on average 72% of the exposure time window, with mean radon concentrations of 76 Bq/m3 among the cases and 74 Bq/m3 among the controls. The smoking- and asbestos-adjusted ORs for categories of radon (50-80, 80-140 and >140 Bq/m*3, compared with 0-50 Bq/m3) were 0.95 (CI = 0.77 to 1.18), 1.13 (CI = 0.86 to1.50) and 1.30 (CI = 0.88 to 1.93). The excess relative risk per 100 Bq/m? was 0.08 (CI = -0.03 to 0.20) for all subjects and 0.09 (CI = -0.06 to 0.27) for subjects with complete measurements for all 30 years. CONCLUSIONS: Our data indicate a small increase in lung cancer risk as a result of residential radon that is consistent with the findings of previous indoor radon and miner studies.     

Glass-based radon-exposure assessment and lung cancer risk

Lung cancer risk estimation in relation to residential radon exposure remains uncertain, partly as a result of imprecision in air-based retrospective radon-exposure assessment in epidemiological studies. A recently developed methodology provides estimates for past radon concentrations and involves measurement of the surface activity of a glass object that has been in a subject's dwellings through the period for exposure assessment. Such glass measurements were performed for 110 lung cancer subjects, diagnosed 1985 to 1995, and for 231 control subjects, recruited in a case-control study of residential radon and lung cancer among never-smokers in Sweden. The relative risks (with 95% confidence intervals) of lung cancer in relation to categories of surface-based average domestic radon concentration during three decades, delimited by cutpoints at 50, 80, and 140 Bq m(-3), were 1.60 (0.8 to 3.4), 1.96 (0.9 to 4.2), and 2.20 (0.9 to 5.6), respectively, with average radon concentrations below 50 Bq m(-3) used as reference category, and with adjustment for other risk factors. These relative risks, and the excess relative risk (ERR) of 75% (-4% to 430%) per 100 Bq m(-3) obtained when using a continuous variable for surface-based average radon concentration estimates, were about twice the size of the corresponding relative risks obtained among these subjects when using air-based average radon concentration estimates. This suggests that surface-based estimates may provide a more relevant exposure proxy than air-based estimates for relating past radon exposure to lung cancer risk.     

Residential Radon and Risk of Lung Cancer in an Italian Alpine Area

To evaluate whether residential radon exposure explains the excess mortality for lung cancer in an Italian alpine valley with high natural radioactivity, the authors conducted a population-based case-control study on 138 deceased cases and 291 sex- and year-of-birth-matched controls. Year-long alpha-track measurements of radon were performed in the most recent residence, and information about occupational history and lifetime smoking habits was obtained. The authors adjusted for smoking, and radon was associated with lung cancer risk among men: compared with a radon level of < 40 becquerels (Bq) per cubic meter (m³), the odds ratios for 40–76 Bq/m³, 77–139 Bq/m³, 140–199 Bq/m³, and 200+ Bq/m³ were 2.1, 2.0, 2.7, and 1.4, respectively. The association between radon and lung cancer, as determined with a multiplicative model, was found only among male smokers.     

Radon mitigation survey among New York State residents living in high radon homes.

Residential exposure to radon has been considered an important environmental risk factor for lung cancer. Since 1986, U.S. EPA has recommended that all dwellings below the third floor be tested for the presence of radon and be mitigated to reduce indoor radon in homes with levels exceeding 148 Bq m(-3). In order to evaluate the effectiveness of New York State Department of Health's efforts to increase public awareness about radon risk and to promote radon testing and mitigation in compliance with EPA's guideline, a statewide radon mitigation survey was conducted between September 1995 and January 1996 among New York State residents whose homes had radon levels equal to or greater than 148 Bq m(-3) on the first floor (or above) living areas. The survey found that about 60% of 1,113 participants had taken actions for radon mitigation. The percentage of respondents who took actions to reduce radon levels in their homes increased with increasing education level as well as household income level. The method of installing a powered system to provide more ventilation was a more effective mitigation method than opening widows/doors or sealing cracks/openings in the basement. Mitigation performed by contractors was more effective in reducing radon levels than mitigation performed by residents. The reasons for performing radon mitigation given by the majority of respondents were those strongly related to radon health risk. High home radon level was an important motivational factor to stimulate radon mitigation. On the other hand, the cost of radon mitigation was a major barrier in decision making for performing radon mitigation and for selecting mitigation measures. Thus, public educational campaigns that focus on increasing awareness and knowledge about radon health risks and development of less expensive radon mitigation methods may help in promoting radon mitigation.     

Increased lung cancer risk due to residential radon in a pooled and extended analysis of studies in Germany

Residential radon has been shown to be a risk factor for lung cancer in several studies-but with limited power in each single study. The data of two case-control studies performed during 1990-1997 in Germany and used for previous publications have been extended and pooled. Both studies have identical study designs. In total, data of 2,963 incident lung cancer cases and 4,232 population controls are analyzed here. One-year radon measurements were performed in houses occupied during the 5-35 y prior to the interview. Conditional logistic and linear relative risk regression was used for the analysis. Measurements covered on average 70% of the exposure time window, with an average radon exposure of 61 Bq m(-3). The smoking and asbestos-adjusted ORs were 0.97 [95% confidence interval (CI) 0.85 to 1.11] for 50-80 Bq m(-3), 1.06 (95% CI 0.87 to 1.30) for 80-140 Bq m(-3) and 1.40 (95% CI 1.03 to 1.89) for radon concentrations above 140 Bq m(-3), compared to the reference category <50 Bq m(-3). The linear increase in the odds ratio per 100 Bq m(-3) was 0.10 (95% CI -0.02 to 0.30) for all subjects and 0.14 (95% CI -0.03 to 0.55) for less mobile subjects who lived in only one home in the last 5-35 y. The risk coefficients generally were higher when measurement error in the radon concentrations was reduced by restricting the population. With respect to histopathology, the risk for small cell carcinoma was higher than for other subtypes. This analysis strengthens the evidence that residential radon is a relevant risk factor for lung cancer.     

Study of radon concentrations in oil refinery premises and city dwellings.

Radon and its progeny concentrations were measured in several dwellings at an oil refinery premises and these concentrations were compared with those found in dwellings in Mathura and Agra cities. Radon progeny concentrations were measured using LR-115 type II nuclear track etch detectors. The radon concentrations were estimated by using a value of 0.42 for the equilibrium factor. The geometric means (GM) of radon concentrations in the refinery dwellings, Mathura city and Agra city dwellings were 97, 91 and 75 Bq m(-3) with geometric standard deviations of 1.7, 1.8 and 1.8 respectively. The average lifetime risk of lung cancer for an adjusted annual average chronic radon exposure of 69 Bq m(-3) (7.8 mWL; WL = working level) with an occupancy factor of 0.7 comes out to be 5.4 x 10(-3).